Botulinum injection for the management of myofascial pain in the masticatory muscles. A prospective outcome study

  • Andrew J. Sidebottom
    Corresponding author. Tel.: +44 115 9249924x65895; fax: +44 115 8493386.
    Maxillofacial Unit, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Derby Road, Nottingham NG7 2UH, United Kingdom
    Search for articles by this author
  • Amish A. Patel
    Biostatistics and Databases Program, The Kirby Institute for Infection and Immunity in Society, The University of New South Wales, Sydney, Australia
    Search for articles by this author
  • Janaki Amin
    Biostatistics and Databases Program, The Kirby Institute for Infection and Immunity in Society, The University of New South Wales, Sydney, Australia
    Search for articles by this author
Published:August 06, 2012DOI:


      We prospectively analysed the outcome after botulinum injection in patients who did not recover after conservative measures to manage masticatory myofascial pain, and who were not willing to take low dose tricyclic antidepressants as a muscle relaxant. We prospectively 62 patients were assessed with visual analogue scores (VAS) for pain on the affected side before, and 6 weeks after botulinum injection(s) (50 units Dysport® in up to 3 sites), and measured mouth opening in mm. Of those treated 49 (79%) showed at least some improvement (pain reduced by more than 25%). Patients reported more than a 90% reduction in the VAS for 25 (30%) of the 84 sides of the face treated. Only 22 of the 62 patients had more than one course of treatment to the same side. Interincisal distance improved by a mean/median of 0.9 mm (p < 0.03) after treatment. Side effects included 3 cases of temporary weakness of a facial muscle. Ranking the VAS pain scores using the Wilcoxon test before and after injection showed a significant reduction in pain (median change −29.5, interquartile range −53 to −16, p < 0.0001). The treatment significantly improved patients’ pain scores and the overall mean/median reduction in pain was 57%. Botulinum injection does not guarantee complete resolution of myofascial pain, but it usually has some beneficial effect in improving the symptoms, and should be considered as an alternate treatment for masticatory myofascial pain if conservative methods have failed.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to British Journal of Oral and Maxillofacial Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kuan T.S.
        Current studies on myofascial pain syndrome.
        Current Pain and Headache Reports. 2009; 13: 365-369
        • Wheeler A.H.
        Myofascial pain disorders: theory to therapy.
        Drugs. 2004; 64: 45-62
        • Chen Q.
        • Bensamoun S.
        • Basford J.R.
        • Thompson J.M.
        • An K.N.
        Identification and quantification of myofascial taut bands with magnetic resonance elastography.
        Archives of Physical Medicine and Rehabilitation. 2007; 88: 1658-1661
        • Sikdar S.
        • Shah J.P.
        • Gilliams E.
        • Gebreab T.
        • Gerber L.H.
        Assessment of myofascial trigger points (MTrPs): a new application of ultrasound imaging and vibration sonoelastography.
        Conf Proc IEEE Eng Med Biol Soc. 2008; 2008: 5585-5588
        • Von Lindern J.J.
        • Niederhagen B.
        • Berge S.
        • Appel T.
        Type A botulinum toxin in the treatment of chronic facial pain associated with masticatory hyperactivity.
        Journal of Oral and Maxillofacial Surgery. 2003; 61: 774-778
        • Jabbari B.
        Botulinum neurotoxins in the treatment of refractory pain.
        Nature Clinical Practice Neurology. 2008; 4: 676-685
        • Aoki K.R.
        Evidence for antinociceptive activity of botulinum toxin type A in pain management.
        Headache. 2003; 43: S9-S15
        • Anderson T.J.
        • Rivest J.
        • Stell R.
        • et al.
        Botulinum toxin treatment of spasmodic torticollis.
        Journal of the Royal Society of Medicine. 1992; 85: 524-529
        • Simons D.G.
        • Travell J.G.
        • Simons L.S.
        Travell and Simons’ myofascial pain and dysfunction: the trigger point manual.
        2nd ed. Williams & Wilkins, Baltimore1992
        • Lang A.M.
        A preliminary comparison of the efficacy and tolerability of botulinum toxin serotypes A and B in the treatment of myofascial pain syndrome: a retrospective, open-label chart review.
        Clinical Therapeutics. 2003; 25: 2268-2278
        • Qerama E.
        • Fuglsang-Frederiksen A.
        • Kasch H.
        • Bach F.W.
        • Jensen T.S.
        A double-blind, controlled study of botulinum toxin A in chronic myofascial pain.
        Neurology. 2006; 67: 241-245
        • Voller B.
        • Sycha T.
        • Gustorff B.
        • et al.
        A randomized, double-blind, placebo controlled study on analgesic effects of botulinum toxin A.
        Neurology. 2003; 61: 940-944
        • Kurtoglu C.
        • Gur O.H.
        • Kurkcu M.
        • Sertdemir Y.
        • Guler-Uysal F.
        • Uysal H.
        Effect of botulinum toxin-A in myofascial pain patients with or without functional disc displacement.
        Journal of Oral and Maxillofacial Surgery. 2008; 66: 1644-1651
        • Seedorf H.
        • Leuwer R.
        • Bussopulos A.
        • Fenske C.
        • Jude H.D.
        Influence of botulinum toxin on myogenous facial pain.
        Schmerz. 2005; 19 ([in German]): 18-25
        • Cheshire W.P.
        • Abashian S.W.
        • Mann J.D.
        Botulinum toxin in the treatment of myofascial pain syndrome.
        Pain. 1994; 59: 65-69
        • Kamanli A.
        • Kaya A.
        • Ardicoglu O.
        • Ozgocmen S.
        • Zengin F.O.
        • Bayik Y.
        Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome.
        Rheumatology International. 2005; 25: 604-611
        • Gül K.
        • Onal S.A.
        Comparison of non-invasive and invasive techniques in the treatment of patients with myofascial pain syndrome.
        Agri. 2009; 21 ([in Turkish]): 104-112
        • Porta M.
        A comparative trial of botulinum toxin type A and methylprednisolone for the treatment of myofascial pain syndrome and pain from chronic muscle spasm.
        Pain. 2000; 85: 101-105
        • Wheeler A.H.
        • Goolkasian P.
        • Gretz S.S.
        A randomized, double-blind, prospective pilot study of botulinum injection for refractory, unilateral, cervicothoracic, paraspinal, myofascial pain syndrome.
        Spine. 1998; 23: 1662-1666
        • Graboski C.L.
        • Gray D.S.
        • Burnham R.S.
        Botulinum toxin A versus bupivicaine trigger point injections for the treatment of myofascial pain syndrome: a randomised double blind crossover study.
        Pain. 2005; 118: 170-175
        • Venancio Rde A.
        • Alencar Jr., F.G.
        • Zamperini C.
        Botulinum toxin, lidocaine, and dry-needling injections in patients with myofascial pain and headaches.
        Cranio. 2009; 27: 46-53
        • Ferrante F.M.
        • Bearn L.
        • Rothrock R.
        • King L.
        Evidence against trigger point injection technique for the treatment of cervicothoracic myofascial pain with botulinum toxin type A.
        Anesthesiology. 2005; 103: 377-383